Correlation Between Obesity and Mental Health Status in Riyadh, Saudi Arabia

Introduction: Recent studies show an increase in the incidence and prevalence of obesity worldwide. In Saudi Arabia, the prevalence of obesity, according to the latest studies, was estimated to be 24.7%. Rising rates of obesity are becoming a serious public health concern with well-documented physical and mental health consequences. Our study aims to measure the effect and the relationship between obesity and mental health status and to assess the impact on the quality of life in Riyadh, Saudi Arabia. Methods: A cross-sectional observational study was conducted in Riyadh, Saudi Arabia. Data collection involved an electronic questionnaire encompassing patient demographics, their perspectives on obesity and its impact on mental health, as well as screening for common mental health disorders using GAD-2 and PHQ-9. Subsequently, the data were coded, entered, and analyzed utilizing both descriptive and inferential statistical methods, with the assistance of IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. Results: A total of 480 adult Saudi participants were included in the current study. Most of them were males (61.5%) in the age group of 18 to 40 years (77.3%). 13.1% of the participants had a first-degree family history of psychiatric illness, and 10.6% had a previous medical history of psychiatric illness. 86% of the participants think that obesity has a negative effect on the quality of life and mental health, and 98.1% believe that losing weight and treating obesity will play a role in improving the quality of life and mental health in general. Regarding the prevalence of mental health issues according to the PHQ-2 score, 151 (31.5%) of the participants were positive, out of whom 47 (31.1%) had mild depression, and 147 (30.5%) of the participants were positive using the GAD-2, out of whom 41 (27.9%) had mild anxiety, and the same percentage had moderate anxiety. There was a significant association between BMI and a previous history of psychiatric illness among females (P = 0.044). Conclusion: Obesity and a higher BMI were found to be associated with a higher prevalence of depression and anxiety among the study participants. About one-third of the total participants had depression, and another one-third had an anxiety disorder.


Introduction
Obesity is a condition in which excess body fat accumulates to such an extent that it could negatively contribute to health [1].It is recognized as a risk factor for various non-communicable diseases such as diabetes mellitus, hypertension, cardiovascular diseases, and musculoskeletal disorders, leading to a significant decrease in life quality and expectancy [2].According to the World Health Organization (WHO), obesity is defined as a Body Mass Index (BMI) greater than or equal to 30 kg/m 2 and is classified into three different classes.BMI is a statistical index that uses a person's weight and height to estimate body fat in males and females of any age, calculated as BMI = weight (in kg)/ height 2 (in m 2 ) [3].
Recent studies indicate a global increase in the incidence and prevalence of obesity [4].In Saudi Arabia, the prevalence of obesity, according to the latest studies, was estimated to be 24.7% [5].The escalating rates of obesity pose a serious public health concern with well-documented physical and mental health consequences [6].Mental health is a state of well-being in which an individual realizes their own abilities, can cope with the normal stresses of life, can work productively, and can contribute to their community.Mental health, rather than just the absence of mental illness, encompasses the presence of positive characteristics [7].In the realm of mental health illnesses, our primary focus is on depression and anxiety.Depression, a common mental disorder, affects an estimated 5% of adults globally, characterized by persistent sadness, lack of interest or pleasure in previously rewarding activities, disturbed sleep, and appetite changes [8].Anxiety disorders involve excessive fear, worry, and related behavioral disturbances, causing significant distress or impairment in functioning [9].A literature search retrieved eleven reviews on obesity and psychological factors, indicating a link between obesity and depression disorders [10].A recent study in Al Kharj, Saudi Arabia, showed a significant association between depression and obesity among participants [11].

Results
A total of 480 adult Saudi participants were included in the current study.Most of them were males (61.5%) and in the age group of 18 to 40 years (77.3%).Regarding their educati onal level; 298 (62.1%) of the participants completed their Bachelor's degree and 128 (26.7%) were completing their postgraduate studies.Majority of the participants had BMI of 18.5 to 24.9 and 25 to 29.9 (31.9% for each).The characteristics of the participants are summarized in Table 1.
Regarding history of psychiatric illness; 63 (13.1%) of the participants had first-degree family history of psychiatric illness and 51 (10.6%) had previous medical history of psychiatric illness while a lower percent (4%) using psychological treatments.413 (86%) of the participants think that obesity has a negative effect on quality of life and mental health (Figure 1).The vast majority of the participants (94.6%) recommended having awareness campaigns and motivational seminars on a regular basis about obesity, its harms, and methods of treating it.Nearly third of the participants (32.5%) had no time to devote to exercising regularly and 101 (21%) exercise half the days of the week (Figure 2).Presence of sports clubs, walking areas, or parks near home enhance practice of sports and quality of life of 446 (92.9%) of the participants and 471 (98.1%) of the participants think that losing weight and treating obesity will play a role in improving the quality of life and mental health in general (Table 2).
In regards to prevalence of mental health issues according to PHQ-2 score; 151 (31.5%) of the participants were positive, out of them 47 (31.1%) were having mild depression and 36 (23.8%) were with moderate depression.On the other hand 147 (30.5%) of the participants were positive using GAD-2, out of them 41 (27.9%) had mild anxiety and the same percent (27.9%) had moderate anxiety (Table 3).
Relationship between gender, educational level and mental health status was assessed.There was a significant association between gender and general mental health status (P = 0.005), females tend to have higher level of mental health issues compared to males (48.1% vs. 35.3%).A significant association was also found between depression and anxiety in relation to educational level (P = 0.032 and 0.003 respectively); participants with bachelor's degree or above having higher level of moderate to severe depression and anxiety compared to those with secondary school education or less.Other variables did not reach the statistical significance level (Table 4).
We found that family history of psychiatric illness was significantly associated with previous medical history of psychiatric illness and use of psychiatric medications (P < 0.001).Previous medical history of psychiatric illness was significantly associated with use of psychiatric medications (P < 0.001) and it was also associated with having mental health problem (P = 0.024).Also there was a significant association between depression, anxiety and previous history of psychiatric illness (P = 0.009 and 0.026 respectively); moderate/severe anxiety and depression were associated with having previous history of psychiatric illness (Table 5).
When we assessed the relationship between physical activity and mental health status the results revealed that having previous history of psychiatric illness was significantly associated with no or once a week physical activity (P = 0.032).Also there was a significant association between physical activity and depression (P < 0.001); moderate/severe depression was associated with no or once a week physical activity (Table 6).
Relationship between BMI and gender, physical activity and mental health status was assessed.There was a significant association between gender and BMI (P < 0.001); females having higher BMI compared to males.There was also significant association between BMI and medical history of psychiatric illness (P = 0.026); having previous medical history of psychiatric illness was associated with higher BMI of 25 to 29.9 and 35 to 39.9.Other variables did not reach the statistical significance level (Table 7).
Relationship between BMI and mental health status in relation to gender was tested.Results showed that there was a significant association between BMI and previous medical history of psychiatric illness among females (P = 0.044); BMI of 35 to 39.9 was associated with having previous medical history of psychiatric illness.Other variable did not show any significance with BMI (Table 8).Positive PHQ-

Variable
Having mental health problem (+ve PHQ-

Discussion
Studying the association and impact of obesity on health and psychological well-being in patients with obesity is crucial, especially its correlation to depression and anxiety, subsequently affecting the quality of life [12].
Regarding the demographic characteristics of the participants, the majority were males (61.5%).More than half (62.1%) of the participants had completed their bachelor's degree.About two-thirds of the participants had a BMI higher than 25.Concerning the history of psychiatric illness, 13.1% of the participants had a firstdegree family history of psychiatric illness, and fifty-one (10.6%) had a previous medical history of psychiatric illness.These findings were consistent with those reported in parallel studies, which showed a slightly higher prevalence [13,14].The vast majority (86%) of the participants believe that obesity has a negative effect on the quality of life and mental health.This sentiment aligns with congruent studies, one reporting the impact of obesity on quality of life, and another study conducted in Saudi Arabia, which reported the correlation between obesity and emotional, social, and behavioral problems associated with physical limitations, also mentioning the negative effects of obesity [15].
Concerning the prevalence of mental health issues according to the PHQ-2 score, 31.5% of the participants tested positive.Out of them, 31.1% were experiencing mild depression, and the rest (23.8%) had moderate depression.This aligns with findings from an analogous study, which reported that 32% of obese people are more likely to have depression [16].Similar results were mentioned in a study conducted in Saudi Arabia in the eastern province, where 41.7% of obese participants had depression [17].One-third (30.5%) of the participants tested positive using the GAD-2, with 27.9% experiencing mild anxiety, and the same percentage (27.9%)had moderate anxiety.This consistency was found in the results of a study conducted in Greece and another study in Saudi Arabia, reporting higher levels of anxiety in obese patients compared to other groups [18].Additionally, prevalent psychological disorders, including depression, anxiety, and stress, were mentioned among obese participants in a Saudi Arabian study conducted in Abha, with the prevalence of depression in obese participants being 48.1%, anxiety at 58.9%, and stress found in 40.4% of the participants [19].
There was a significant association between gender and general mental health status, with females tending to have a higher level of mental health issues compared to males.Analogous findings were mentioned in congruent studies [20,21,22,23].Additionally, it was found that a family history of psychiatric illness was significantly associated with a previous medical history of psychiatric illness and the use of psychiatric medications.This was also reported in the parallel study conducted by Ali et al., where the association between a family history of psychiatric disorders and major psychiatric disorders was found [24].
A statistically significant association was found between physical activity and depression; moderate/severe depression was associated with no or once-a-week physical activity and this was found to be in agreement with the findings of the studies [25,26,27].
Gender and BMI were found to be significantly associated, with females having a higher BMI compared to males.This observation is closely related to findings reported in the study by Cooper et al. and other studies [28,29].
The results also revealed a significant association between BMI and the previous medical history of psychiatric illness among females, where a BMI of 35 to 39.9 was linked to having a prior medical history of psychiatric illness.Additionally, there was a significant association between BMI and the overall medical history of psychiatric illness; having a previous medical history of psychiatric issues was associated with higher BMI values in the ranges of 25 to 29.9 and 35 to 39.9.These findings are consistent with what was reported in the Simon study [30].

Conclusions
the study revealed a noteworthy association between obesity and elevated BMI, with a higher prevalence of both depression and anxiety among the participants.Approximately one-third of the total participants exhibited symptoms of depression, while an additional one-third manifested symptoms of an anxiety disorder.Importantly, the study emphasized the significance of a family history of psychiatric disorders as a crucial factor contributing to the heightened prevalence of specific psychiatric conditions.These findings underscore the imperative need for targeted interventions addressing obesity and its potential impact on mental health, particularly when considering the context of familial psychiatric history.
Recommendations: Further research endeavors and heightened awareness initiatives aimed at developing effective strategies to alleviate the dual burden of obesity and mental health disorders, thereby fostering comprehensive well-being as a part of Vision 2030 with encouraging exercises to reduce obesity and lower BMI.

FIGURE 1 :FIGURE 2 :
FIGURE 1: Do you think that obesity has a role and impact on quality of life and mental health?

TABLE 4 : Association between gender, educational level and mental health status
p value calculated using Fisher's exact test, other p values calculated using Chi-square test.* Significant p value < 0.05.

TABLE 5 : Association between history of Psychiatric illness and mental health status
p value calculated using Fisher's exact test, other p values calculated using Chi-square test.* Significant p value < 0.05.

TABLE 6 : : Association between physical activity and mental health status
p values calculated using Chi-square test.* Significant p value < 0.05.

TABLE 7 : Association between BMI and gender, physical activity and mental health status
p value calculated using Fisher's exact test, other p values calculated using Chi-square test.* Significant p value < 0.05

TABLE 8 : Association between BMI and mental health status stratified by gender.
p value calculated using Fisher's exact test, other p values calculated using Chi-square test.* Significant p value < 0.05.